Implantable cardiac prosthesis with active detection of atrial mechanical activity

ABSTRACT

A device includes a lead configured to for use in applying an atrioventricular delay (“AVD”), an acceleration sensor adapted to output an endocardial acceleration signal, and circuitry configured to receive and process said endocardial acceleration signal to provide ventricular pacing by varying, in a controlled manner, the AVD in a range having a plurality of AVD values. The circuitry derives from said endocardial acceleration signal a value of a parameter representative of an component of the endocardial acceleration signal corresponding to the first endocardial acceleration peak associated with an isovolumetric ventricular contraction (“EAX component”), and evaluates a degree of variation of said parameter values as a function of said plurality of AVD values to detect atrial and ventricular events.

CROSS-REFERENCE TO RELATED APPLICATION

This application claims the benefit of and priority to French PatentApplication No. 1261424, filed Nov. 29, 2012, which is incorporatedherein by reference in its entirety.

BACKGROUND

The device relates to “active implantable medical devices” as defined bythe Directive 90/385/EEC of 20 Jun. 1990 the Council of the EuropeanCommunities. More specifically, the device relates to implants tocontinuously monitor heart rhythm and which are capable of delivering tothe heart electrical pulses for stimulation, resynchronization and/ordefibrillation in case of arrhythmia detected by the device.

The device also relates to the diagnosis of atrial contractiondisorders. These disorders usually appear as aftermath of an episode ofatrial fibrillation (AF). Atrial fibrillation is an arrhythmiacharacterized by abnormally high frequency of the atrial rhythm. Atrialcontraction disorders may also result from other conditions such asatrial ischemia or dilated atrium by sarcoidosis or fibrosis. After anepisode of AF, the contraction of the myocardium at the atrium isdeficient or absent, despite the presence of a spontaneous or stimulatedobservable electric depolarization wave. An atonic atrium muscle leadsto a lower contribution from the atrium muscle to fill the ventricle.This results in a very marked deterioration in hemodynamic performance.In such a situation, it may not be possible to optimize a double chamberoperation of a device with atrial and ventricular sensing andventricular stimulation. In this mode, the device triggers whenventricular pacing may be required or desirable after a predeterminedatrioventricular delay (AVD). The AVD is counted from the detection of aspontaneous or paced atrial event. This AVD is normally adjusted tooptimize the overall functioning of the heart from the hemodynamic pointof view. In the case of atrial atony, the normal electrical activitycauses the application of the AVD. However, it is challenging tooptimize this delay because the actual behavior of the atrium is notknown.

With the exception of an exploration by echocardiography, it ischallenging to determine whether, after an episode of AF, a patient hasrecovered to normal mechanical atrial activity. It is also challengingto determine when that recovery has occurred. Furthermore, it ischallenging to determine if there is an atrial atony, an absent ordeficient contraction of the atrium despite an observable electricalactivity (sinus rhythm).

SUMMARY

One embodiment of the device relates to evaluating the mechanicalactivity of the atrium, especially the return to normal atrial activityafter an episode of AF. The device may also be capable of diagnosing thepresence of atrial atony.

In one embodiment of the invention, the device evaluates the mechanicalactivity of the atrium by measuring an endocardial acceleration signal(EA). EA is a parameter of a component related to the mechanicalactivity of the ventricle and related to the modulation of the AVD. Ifthe result of this modulation is a significant variation of theparameter in question, then this reflects the correct mechanicalactivity of the atrium. Conversely, the absence of significant change inthe parameter may indicate an absent of or degraded atrial activity.With such an analysis, an implantable device can automatically establishthe state of the atrial activity of the patient. Further, theimplantable device, using this analysis, can determine when the patienthas regained normal mechanical atrial activity after an episode of AF.Moreover, in the absence of proven atrial mechanical activity, it ispossible to disable algorithms which would be ineffective in the absenceof such activity. For example, AVD automatic optimization algorithms canbe disabled.

U.S. 2007/0179542 A1 describes a device including methods of adjustmentof the AVD allowing dynamic optimization of the patient's hemodynamicstatus. The device is further capable of detecting the presence orabsence of atrial fibrillation, an atrial tachycardia episode or otherpathological episodes of the same nature of the atrium. The device mayalso inhibit the adjustment of the AVD during the duration of such aproven episode. An adjustment calculation made during an episode wouldbe strongly biased by the patient's medical condition and could resultin deleterious effects in the patient.

In some embodiments, the device disclosed herein may not take actionaccording to the presence or absence of an episode of atrialfibrillation. The device, once the fibrillation has ended, assesses thequality (i.e., normal, toneless or virtually absent) of the atrialcontraction in sinus rhythm, i.e. the quality of the mechanical activityof the atrium when the latter has an observable electrical activity.

To this end, some embodiments of the device include an activeimplantable medical device such as a cardiac prosthetic for pacing,resynchronization and/or defibrillation. Some embodiments include adetector for detecting atrial and ventricular events. Some embodimentsinclude a pacer for ventricular pacing. Also included may be methods forapplying an atrioventricular delay AVD, counted from the detection of aspontaneous or stimulated atrial event and after which a ventricularstimulation is delivered in the absence of detection of a correspondingspontaneous ventricular event, to the stimulation methods. Someembodiments also include an acceleration sensor adapted to output anendocardial acceleration signal (EA) representative of the movementsproduced by the cyclical contractions of the myocardium. Someembodiments of the device include methods to analyze the EA signal.These methods derive, from the EA signal, a value EA of a representativenon-temporal EA ventricular parameter of a component EA1 of the signalcorresponding to the first peak EA associated with the isovolumetricventricular contraction. Further included within some embodiments of thedevice are scanning methods, capable of varying in a controlled mannerthe AVD. The AVD is varied in a range having a plurality of AVD values.Some embodiments also include a quantifier, for evaluating a degree ofvariation of the ventricular EA parameter corresponding to a pluralityof values of the AVD.

In addition to the features disclosed in U.S. 2007/0179542 A1, someembodiments of the device, further include a detector which is capableof discriminating between: i) a normal atrial mechanical activity, andii) an absent or deficient atrial mechanical activity despite anobservable electrical activity in sinus rhythm. The embodimentdiscriminates as a function of the degree of variation in thenon-temporal ventricular EA parameter estimated by the quantifierdescribed above.

The non-temporal ventricular EA parameter can notably be thepeak-to-peak amplitude of the EA signal of the EA1 component. Thenon-temporal ventricular EA parameter may also be the energy of the EA1component.

In a first embodiment of the device, there is a range of values of theAVD including a first range with a plurality of short AVD and a secondrange with a plurality of long AVD. The second range of AVD values isdistinct from the first one. The quantifier assess the degree ofvariation in the non-temporal ventricular EA parameter by computing adifference between the values of the EA ventricular parameter collectedfor the first range of AVD values and the values of the EA ventricularparameter collected for the second range of AVD values. The detectordiscriminates between a normal atrial mechanical activity and an absentor deficient atrial mechanical activity. When the difference between theEA ventricular parameters for different AVD values exceeds apredetermined threshold, there is normal atrial activity. When thethreshold is not exceeded, the atrial activity is absent or deficient.

In a second embodiment of the device, the quantifier is adapted toevaluate the degree of variation in the EA ventricular parameter bycomputing a standard deviation of the EA ventricular parameter valuescollected for the various AVD of said range of values. The detector,capable of detecting atrial activity, is able to discriminate between anormal atrial mechanical activity and an absent or deficient atrialmechanical activity. When the standard deviation exceeds a predeterminedthreshold, the atrial mechanical activity is normal. When the standarddeviation calculated by the quantifier does not exceed the predeterminedthreshold, there is absent or deficient atrial mechanical activity.

In a third embodiment of the device, the quantifier is adapted toevaluate the degree of variation by modeling the sigmoid characteristicof variation in the EA ventricular parameter as a function of AVD rangevalues, with two plateaus on either side of a central transitionportion. The detector, for detecting atrial activity, is able todiscriminate between a normal atrial mechanical activity when theabsolute difference in the level of the two plateaus is larger than apredetermined threshold. An absent or deficient atrial mechanicalactivity is detected when absolute difference of the two plateaus isless than the predetermined threshold.

In some embodiments of the device, the techniques described above may beused to store an index function of the degree of variation of the EAventricular parameter as a function of the plurality of AVD values.Additionally, the index function may be used to form a history of theevolution of the index over time.

In embodiments where the device further includes a stimulation device,for atrial stimulation, it is possible for the embodiment to implement adetector for detecting atrial activity in the presence of a spontaneousatrial event. The detector may detect atrial activity related to anatrial paced event. The detector may compare the respective storedvalues of the index and derive from this comparison a warning indicatorin case of discrepancy with the respective compared index. In the caseof an episode of atrial fibrillation, it is possible to compare thestored values of that index, prior to and after the episode of atrialfibrillation, and derive from this comparison an indicator of recoveryor no recovery from the atrial fibrillation.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 is a series of graphs illustrating three different characteristicsignals that can be collected during a cardiac cycle.

FIG. 2 shows in more detail the shape of the endocardial accelerationsignal during a given cycle.

FIGS. 3 a-3 c show the classic form of a variation of the amplitude ofthe first peak of the EA signal versus the AVD characteristic for ahealthy subject (FIG. 3 a) and with the changes that this characteristicmay present in case of an absence of atrial mechanical activity (FIG. 3b) or in case of atrial atony (FIG. 3 c).

FIGS. 4 a and 4 b illustrate a first technique for analyzing thecharacteristic of FIG. 3 a to discriminate between normal and abnormalor absent atrial activity.

FIGS. 5 a and 5 b are counterparts of the previous figures illustratinga second analysis technique.

FIGS. 6 a and 6 b are counterparts of the previous figures illustratinga third analysis technique.

FIG. 7 illustrates, according to one embodiment, the manner ofmonitoring, over several weeks, the atrial activity in the case whereinit is considered normal.

FIG. 8 is a counterpart of FIG. 7 illustrating, according to oneembodiment, the case of an episode of atrial fibrillation lasting forseveral weeks, in which a deficient mechanical atrial activity ismonitored until the activity can be considered as returned to normal.

FIG. 9 is a flowchart schematically describing the sequence over time ofthe different steps of monitoring and diagnosis of the atrial activityaccording to one embodiment.

DETAILED DESCRIPTION

An exemplary embodiment of the device is illustrated with reference tothe accompanying drawings as described below.

Aspects of the device may be applied to implantable devices such as theParadym family (especially Paradym RF SonR CRT-D) produced and marketedby Sorin CRM, Clamart, France.

These are programmable microprocessor devices including circuitry toreceive, format and process electrical signals collected by implantedelectrodes. These devices also deliver stimulation pulses to electrodes.It is possible, using telemetry software that is stored in memory and isexecuted, to implement some of the features of the device that aredescribed below (parameter optimization and monitoring of the patient'sstatus). The adaptation of these devices for the implementation of thefunctions of some of the embodiments of the device is within the skillin the art and is not described in detail.

The technique used in some embodiments of the device is based on theanalysis of the endocardial acceleration (hereinafter “EA”). EA is aparameter that reflects very precisely, and in real time, phenomenacontributing to the mechanical operation of the myocardium. EA may bemeasured by an accelerometer coupled to the heart muscle. This techniqueis described, for example, in EP 0515319 A1 (Sorin Biomedica CardioSpA). This document discloses the method to collect an EA signal throughan endocardial lead with a stimulation distal electrode implanted in theatrium or in the ventricle. A microaccelerometer is included formeasuring endocardial acceleration.

Such a sensor as a the one described in EP 0515319 A1 or anothermicroaccelerometer may be arranged on an endocardial lead terminating atthe apex of the ventricle. An acceleration sensor is provided at thatlocation. The sensor may also be a lead provided with an accelerationsensor at its one end disposed against the wall of the right atrium.Note that although the present description refers mainly to the analysisof an EA signal delivered by a sensor on an endocardial lead, someembodiments of the device may perform an analysis using an EA signaldelivered by other types of implantable sensors. For example, theseimplantable sensors may include a motion sensor of a wall of themyocardium, an epicardial sensor, or an accelerometer in the housing ofan implant. Some embodiments of the device are also applicable ofperforming the analysis using an external EA signal obtainednon-invasively. For example, a sensor may be attached to the patient'schest at the sternum.

FIG. 1 illustrates the various signals characterizing the activity ofthe heart during a cardiac cycle. The profiles of intracardiac pressuresP_(A), P_(VG) and P_(OG) are shown. The P_(A) profile shows the changesin the aortic pressure. The P_(VG) profile shows changes in the leftventricular pressure. The P_(OG) profile shows changes in the leftatrium pressure. These changes go through phases including: acontraction of the left atrium, closure of the mitral valve (MC),opening of the aortic valve (AO), closure of the aortic valve (AC), andopening of the mitral valve (MO). An ECG surface electrocardiogram plotis also shown corresponding to the same period of time. The ECG surfaceelectrocardiogram plot includes the P wave corresponding to thedepolarization of the atria, the QRS complex corresponding to thedepolarization of the ventricles, and the T wave of ventricularrepolarization. Also shown are the changes in the collected EAendocardial acceleration signal. The EA endocarial acceleration signalforms two main components EA1 and EA2 during a given cardiac cycle. Thetwo main components correspond to the two major heart sounds (S1 and S2sounds of the phonocardiogram) that can be recognized in each cardiaccycle.

In FIG. 2, changes in the EA signal during a cardiac cycle are morespecifically illustrated. The EA1 component begins after the QRS complexand is caused by a combination of the closing of the atrioventricularvalves (the mitral and the tricuspid valves), the opening of semilunarvalves (the aortic and the pulmonary valves), and the contraction of theleft ventricle. The amplitude variations of this EA1 component areclosely related to changes in the pressure in the ventricle. The maximumpeak-to-peak PEA1 is specifically correlated to the positive maximum ofthe pressure variation dP/dt in the left ventricle. The EA2 componentoccurs during the isovolumetric ventricular relaxation phase. Itsupports the end of the ventricular systole and is mainly produced bythe closure of the aortic and pulmonary valves.

For the implementation of some embodiments of the device, the device mayextract from the EA signal, specifically from the EA1 component, anon-temporal parameter characteristic of the magnitude of this EA1component. This parameter can particularly be the PEA1 amplitude of thefirst peak of endocardial acceleration. PEA1 amplitude is the maximumpeak-to-peak value between the positive and negative extremes of the EA1component of the acceleration signal. This PEA1 parameter is used in thefollowing description as a significant non-temporal parameter. In someembodiments, other parameters representative of the magnitude of EA1component may be used.

In particular, it is possible to use as a significant non-temporalparameter the energy of the EA signal contained in all or part of theEA1 component. This energy is given by the root mean square (RMS) valueof a series of samples considered for a predetermined time window of theEA1 component. This energy parameter is illustrated in FIG. 2 by theenvelope E of the signal.

The analysis of the EA signal is preferably determined with averagingover several cycles, typically three to five cycles, using a techniquesuch as that disclosed in EP 2092885 A1 (ELA Medical). This technique isuseful for eliminating the cycle to cycle variations by a timing shiftof the successive components before averaging.

Essentially, this technique is to pre-process the continuously collectedEA signal. The EA signal is cut into sub-signals each corresponding tothe duration of a cardiac cycle and identified by cycle start markers(time origin) for performing this cutting cycle. The cycle starttemporal markers can be provided by the implanted device. The devicealso, according to the operating mode, stores the moments of Vstimulation or the moments of R wave detection. Each of thesesub-signals is segmented so as to individualize the EA1 component in agiven temporal window. For the current EA1 component thus isolated on acycle, an inter-correlation peak relative to the EA1 components of theother collected cycles is determined. A corresponding temporal shift iscomputed. The calculated temporal shift is applied to the current EA1component so as to align it with respect to the others. The analysisprocessing of the EA signal can then be executed on successive EA1components, eliminating cycle to cycle variability bias through thispre-processing.

In some embodiments of the device, atrioventricular delay (AVD) ismodulated. The changes to the non-temporal characteristic parameter ofthe EA signal, in this example the PEA1 amplitude, are produced by thismodulation of the AVD.

The variation of the PEA1 amplitude with the AVD is normally associatedwith a sigmoid shape characteristic S, shown in FIG. 3 a. In this figureand the following ones, the thin line circles indicate the differentreadings in successive cardiac cycles for the same applied AVD value.The thick line circles correspond to the value of these differentmeasures averaged for a same AVD.

The PEA1 amplitude decreases when the AVD increases, and the sigmoidcharacteristic can be modeled in a simplified form MS with two plateausP1, P2 respectively corresponding to the short AVD and to the long AVD,these plateaus being separated by a central transition portion with anegative slope.

Some embodiments of the device are based on the idea that changes in theEA1 characteristic versus the AVD, such as changes in the PEA1amplitude, are due, among other factors, to the different contributionof the atrium for the filling of the ventricle. A short AVD maximizesthe filling of the ventricle, leading to a very marked EA peak signal. Along AVD reduces the amplitude and the energy of the EA1 component.

When the atrial mechanical activity is absent, typically after anepisode of atrial fibrillation (AF), the atrium may fail to contributein any way to fill the ventricle. A variation of the AVD produces nosignificant change in the EA1 component. This situation is illustratedin FIG. 3 b. The level of the PEA1 amplitude is essentially the sameregardless of the applied, short or long, AVD.

In the case of a present but deficient atrial contraction (atrialatony), the PEA1 amplitude varies slightly with the AVD (shown FIG. 3 cstatus). The variation of the PEA1 amplitude with respect to AVD is muchless than in the case of a full atrial contraction (FIG. 3 a).

Different techniques can be used to analyze the PEA1/AVD characteristicand discriminate between normal atrial activity and absent or deficientatrial activity. Some embodiments may include a first technique, aloneor in conjunction with other techniques. The first technique isillustrated with reference to FIGS. 4 a and 4 b. A number N of shorttest AVD values are applied. Separately, a number N of long test AVDvalues are applied. The PEA1 amplitude is measured for each of theseapplied AVD values.

The test AVD are selected from a bounded range of values. For example,some embodiments may use minimum values DAV_(min)=32 ms for the shortestvalue and maximum DAV_(max)=PR-50 ms for the longest AVD. PR is theinterval between the atrial and ventricular depolarizations and 50 mscorresponds to a predetermined safety margin in this example. In someembodiments, the number N, which defines the number of long and shortAVD to test, can be for example between 3 and 20. The different testedAVD are performed with a fixed pitch, for example 15 ms between twoconsecutive AVD.

For each tested AVD, the PEA1 amplitude is measured and averaged over anumber of cycles. For example, some embodiments may take measurementsfor six or more cardiac cycles.

To determine the level of atrial activity, a difference is calculatedbetween the average values of PEA1 measured for the N short AVD, and theaverage values of PEA1 measured for the N long AVD. If this absolutedifference is less than a programmable threshold, there is an absence ofnormal mechanical atrial activity (as in FIG. 4 b). In other words,there is absent or deficient atrial activity. If the absolute differenceis greater than the programmable threshold, there is normal mechanicalatrial activity. In some embodiments, the value of the calculateddifference is preferably stored in memory. The stored values mayconstitute a history that may be used to monitor the long-term atrialmechanical activity. This is explained below with reference to FIGS. 7and 8.

Some embodiments may use a second technique, alone or in conjunctionwith other techniques, to analyze the PEA1/AVD characteristic anddiscriminate between normal atrial activity and absent or deficientatrial activity. This second technique is illustrated with reference toFIGS. 5 a and 5 b. The AVD is regularly modulated with a scan betweenthe DAV_(min) and DAV_(max) values. This can be done to obtain a numberN of successive measurements of equidistant AVD values. In someembodiments, N may typically be between 4 and 20. For each tested AVD,the PEA1 amplitude is measured and averaged over several cycles. In someembodiments, the PEA1 amplitude is measured for typically at least sixcardiac cycles.

The standard deviation SD_(PEA1) is then calculated from all theaveraged values of PEA1. If the standard deviation is below a giventhreshold, then there is no normal mechanical atrial activity (as inFIG. 5 b). There is absent or deficient atrial activity. If the standarddeviation SD_(PEA1) is greater than the given threshold, there is normalmechanical atrial activity. In some embodiments, the value of thecalculated standard deviation may be stored in memory to monitor thelong-term atrial mechanical activity of the patient.

Some embodiments may use a third technique, alone or in conjunction withother techniques, to analyze the PEA1/AVD characteristic anddiscriminate between normal atrial activity and absent or deficientatrial activity. The third technique is illustrated with reference toFIGS. 6 a and 6 b. The third technique is a variant of the secondtechnique described above. This technique operates by creating a MSmodel of the PEA1 characteristic obtained after scanning the range ofpossible AVD between DAV_(min) and DAV_(max).

As noted above, the modeled characteristic has two plateaus, P1 for thelowest AVD values and P2 for the highest AVD values. This is typical ofa sigmoid shape. The atrial activity is estimated by calculating theabsolute difference ΔP between the two plateaus P1 and P2 of the sigmoidapproximation. If this difference is less than a given threshold, thenthere is an absence of normal atrial mechanical activity (as in FIG. 6b). In other words, there is absent or deficient atrial activity. If thedifference is greater than the given threshold, there is normalmechanical atrial activity.

FIGS. 7 and 8 and the flow chart of FIG. 9 illustrate the possibility ofusing the atrial mechanical activity test techniques described above tomonitor the patient's long-term clinical status. In some embodiments, atest can be triggered periodically. For example, the test may occurweekly or more frequently to determine the status of the atrialactivity. This test may be run for both spontaneous and stimulatedatrial depolarization. In the case of stimulated atrial activity, thetest may occur in conditions in which atrial capture is likely. Tofacilitate atrial capture, stimulation amplitude is adjusted at a highlevel during the test. In some embodiments, stimulation amplitude ispreviously checked for the presence of an actual atrial capture.

For testing, the AVD is modulated in order to evaluate a degree ofvariation of the EA1 characteristic versus the AVD according to one ofthe techniques described above. For example, the difference Δ_(PEA1)calculated between the PEA1 amplitude collected for the short AVD andthose collected for the long AVD may be stored. This corresponds withthe first technique for discriminating between normal atrial activityand absent or deficient atrial activity described above. Someembodiments may use a different combination of one or more of thetechniques described. If this Δ_(PEA1) value is greater than a giventhreshold S, atrial activity is present and normal. If the Δ_(PEA1)value is less than a given threshold, atrial activity is absent ordeficient (atrial atony). In some embodiments, the device compares therespective values of the Δ_(PEA1) stored value in the presence of aspontaneous atrial event and in the presence of an atrial paced event.The device may generate an alert in the case of a discrepancy betweenthe compared values.

FIG. 7 shows an example in which the Δ_(PEA1) value is evaluated atweekly intervals (W1, W2, W3, . . . ). The Δ_(PEA1)value correspondingto each week is stored. These stored values may be used to form along-term history of global atrial mechanical activity of the patient.FIG. 7 illustrates a normal atrial mechanical activity history. S is athreshold value against which the Δ_(PEA1) value for each week iscompared. Each week shows normal atrial mechanical activity as theΔ_(PEA1) value is above the threshold value S. In a case where theΔ_(PEA1) value is below the threshold value S, atrial activity is absentor deficient (atrial atony).

FIG. 8 shows an example of an episode of atrial fibrillation AF leavingdeficient mechanical atrial activity for several weeks. The end of thisepisode (between periods W4 and W8) can be detected by a return of sinusrhythm. The test for mechanical atrial activity is then performed usingone of or a combination of the techniques described above. In theexample illustrated by FIG. 8, the test indicates that during theperiods W9 to W12 there was deficient atrial activity. The degree ofPEA1/AVD variation is less than the threshold S. The patient hasregained normal atrial activity when Δ_(PEA1) rises above thisthreshold. For example, the threshold may be S′=80% of the Δ valuerecorded by the Δ_(PEA1) variation parameter prior to the AF episode.

FIG. 9 illustrates a schematic of the successive steps of an algorithmto discriminate between the various possible states of atrial mechanicalactivity after an episode of atrial fibrillation. For a patient withatrial fibrillation (block 10), the device waits for the end of thisepisode (block 12). The end of the episode is detected by the return toa normal and stable sinus rhythm. The return to a normal and stablesinus rhythm may be determined by the analysis of the electricalactivity of the depolarization signals detected at the atrium.

The device may then perform a test to assess the degree of variation ofthe PEA1 amplitude versus the AVD (block 14). The resulting test data iscollected and stored. If test results were obtained and stored beforethe AF episode (block 16), then the algorithm compares the new data tothe old data (block 20). If the data values are comparable (for example,if the Δ_(PEA1) variation parameter is at least 80% of the value it hadbefore the episode of AF), the atrial activity returned to normal. Ifthe test data values are not comparable to the values stored before theAF episode, the atrial activity is insufficient or absent.

If there is no data prior to the AF episode, the algorithm simplycompares the test data to a threshold (block 18). If the test datavalues are greater than the threshold, there is normal mechanical atrialactivity. If the test data values are less than the threshold, there isreduced or absent atrial activity. In some embodiments, the algorithmmay use a combination of one or more of the techniques fordiscriminating between normal and absent or deficient atrial activitydescribed above.

In some embodiments, the analysis of the atrial mechanical activity mayalso be used to selectively enable or disable various algorithms. Thesealgorithms may include atrial overdriving, automatic optimization of theAVD, etc., depending on the test result.

For example, if atrial fibrillation is detected, using the analysispreviously described herein, then the AVD algorithm may be disabled.Continued use of the AVD algorithm during atrial fibrillation may havedeleterious effects. These effects may be prevented by the disabling ofthe AVD algorithm during episodes of atrial fibrillation detected by thedevice. In some embodiments, an atrial overdriving algorithm, designedto overdrive the atrium to prevent atrial fibrillation through a higherpacing rhythm, may be activated or enabled by the device. The device mayenable this algorithm upon the detection of atrial fibrillation usingthe analysis previously described herein. In some embodiments, thesealgorithms may be disabled, enable, and/or modified depending on thedetection of normal or deficient or absent atrial mechanical activityaccording to the analysis described herein. Furthermore, in someembodiments the device and/or analysis may automatically optimize theAVD using the techniques described herein (e.g. upon detection of absentor deficient atrial mechanical activity). In some embodiments, thedevice may produce an alert (e.g. signal, notification, data point,sound, visible signal, etc.) in certain cases. For example, the devicemay produce an alert when an algorithm is enabled, disabled, and/ormodified. Continuing the example, the device may produce an alert uponthe detection, using the analysis described herein, of absent ordeficient atrial mechanical activity. The device may adjust a variableof an AVD algorithm. For example, the device may adjust one or more ofthe length of time of the AVD, the length of the time intervals betweenatrial sensing, the length of the time intervals between pacing, thenumber of cycles for which an extended or reduced AVD is applies, thevalue of and AVD extension, the value of an AVD reduction, the value ofthe AVD corresponding to different heart rates, the magnitude of theventricular pacing stimulus, the rate adjustment value for exercise andother activities, the base pacing rate, etc. The AVD may be adjustedtaking into account the optimal or desired interatrial conduction time,left-atrial electromechanical action, left-ventricular latency period,etc. The device may also adjust a variable of an atrial overdrivingalgorithm. For example the device may adjust one or more of rate ofpacing, the frequency of stimulation, the magnitude of stimulation, theatrial rate, the rate adjustment value for exercise and otheractivities, the base pacing rate

In one embodiment of the device, the device is not a pacing device. Thedevice may be a monitor, server computer, personal computer, mobiledevice, clinic computer, or other device configured to apply theanalysis techniques described. The device may also be configured todiscriminate between normal and absent or deficient atrial mechanicalactivity and/or to determine if a patient is experiencing AF using theanalysis techniques described above. In some embodiments, the device maybe incorporated into another apparatus such as a patient bed, heart ratemonitor, etc. Having received data such as the EA signal for a patientover time or a set of non-temporal EA ventricular parameter values overtime (e.g. PEA1 amplitude or energy of the EA1 component of the EAsignal), the device may perform the analysis techniques set forth above.The results of the analysis may be a determination of normal atrialmechanical activity or absent or deficient atrial mechanical activity.This determination may be over a period of time and/or live as data isreceived. For example, the device may display a graph such as the oneillustrated in FIG. 7 or FIG. 8. The device may display a graph of thechange of the non-temporal EA ventricular parameter values for differentAVD values over time. The device may also label periods of normal atrialmechanical activity. The device may label periods of absent or deficientatrial mechanical activity. The device may also provide a currentdetermination of whether a patient is experiencing AF. Thisdetermination may be based on the most recently available data. Thisdetermination may be presented to a user of the device through an alert.For example, the alert may be a visual warning (e.g. graphics or wordswhich designate that the patient is experiencing AF), an auditorywarning (e.g. an alarm when the patient is experiencing AF), or awarning otherwise delivered. In the case that the patient is notexperiencing AF, a status indicator may be displayed to the user of thedevice. The analysis, analysis results, and/or warnings generated by thedevice may be displayed and/or delivered to a user. For example, theanalysis and/or alerts may be displayed on a local monitor, remotemonitor, emailed to a user, sent to a mobile device, pushed to anapplication on a mobile device, compiled into a report and printed, sentas a text message, sent as a page, broadcast over a public addresssystem (e.g. in the case of an AF alert), displayed on a computer and/ormonitor at a nurses station, stored locally, stored in a cloud basedarchitecture, transferred to another computing device etc. In someembodiments, the device may compare analyzed data to a data in a storedindex for a particular patient. This comparison and/or the resultinganalysis may displayed in a manner described above.

1. A device, comprising: a lead having at least one electrode; anacceleration sensor adapted to output an endocardial accelerationsignal; circuitry configured to receive and process said endocardialacceleration signal and to provide ventricular pacing using the lead byvarying, in a controlled manner, an atrioventricular delay (“AVD”) in arange having a plurality of AVD values, wherein the circuitry derivesfrom said endocardial acceleration signal a value of a parameterrepresentative of a component of the endocardial acceleration signalcorresponding to the first endocardial acceleration peak associated withan isovolumetric ventricular contraction (“EAX component”), andevaluates a degree of variation of said parameter values as a functionof said plurality of AVD values to detect atrial and ventricular events.2. The device of claim 1, wherein the AVD is counted from the detectionof a spontaneous or stimulated atrial event and after which aventricular stimulation is delivered in the absence of detection of acorresponding spontaneous ventricular event.
 3. The device of claim 1,wherein the circuitry is configured to discriminate, as a function ofsaid degree of variation of parameter values, between normal atrialmechanical activity and an absent or deficient atrial activity, despitean observable electrical activity in sinus rhythm.
 4. The device ofclaim 1, wherein said parameter is the amplitude between extremes of theEAX component of the endocardial acceleration signal.
 5. The device ofclaim 1, wherein said parameter is the energy of the EAX component ofthe endocardial acceleration signal.
 6. The device of claim 1, whereinthe circuitry is configured to evaluate said degree of variation of saidparameter values as a function of said plurality of AVD values bycalculating a difference between the values of the parameter collectedfor a first range of AVD values and the values of the parametercollected for a second range of AVD values, and wherein said first rangeof AVD values includes a plurality of short AVD values and said secondrange of AVD values, distinct from said first range of AVD values,includes a plurality of long AVD values.
 7. The device of claim 6wherein the circuitry is configured to discriminate between a normalatrial mechanical activity, when said difference exceeds a predeterminedthreshold, and an absent or deficient atrial mechanical activity whensaid difference does not exceed said predetermined threshold.
 8. Thedevice of claim 1, wherein the circuitry is configured to evaluate saiddegree of variation of said parameter values as a function of saidplurality of AVD values by calculating a standard deviation of theparameter values collected for said plurality of AVD values.
 9. Thedevice of claim 8, wherein the circuitry is configured to discriminatebetween a normal atrial mechanical activity, when said standarddeviation exceeds a predetermined threshold, and an absent or deficientatrial mechanical activity when said standard deviation does not exceedsaid predetermined threshold.
 10. The device of claim 1, wherein thecircuitry is configured to evaluate said degree of variation of saidparameter values as a function of said plurality of AVD values bymodeling a sigmoid characteristic of the parameter values as a functionof said plurality of AVD values, with two plateaus, one on each side ofa central transition portion.
 11. The device of claim 10, wherein thecircuitry is configured to discriminate between a normal atrialmechanical activity, when the absolute level difference of the twoplateaus is larger than a predetermined threshold, and an absent ordeficient atrial mechanical activity when the absolute level differenceof the two plateaus is not larger than said predetermined threshold. 12.The device of claim 1, further comprising memory configured to store anindex of said degree of variation of the parameter values, wherein saidmemory is further configured to provide a history of the evolution ofsaid index over time.
 13. The device of claim 12, further comprising: astimulation device configured to provide atrial stimulation; and whereinthe circuitry is configured to provide an atrial paced event, andwherein the circuitry is configured to detect atrial activity in thepresence of at least a spontaneous atrial event and at least an atrialpaced event, and wherein the circuitry is configured to compare storedvalues of said index corresponding to the spontaneous atrial event withstored values of said index corresponding to the paced atrial event andto derive from this comparison a warning indicator in case ofdiscrepancy between the respective compared indexes.
 14. The device ofclaim 12, wherein the circuitry is configured to, upon the occurrence ofan episode of atrial fibrillation (AF), compare the stored values ofsaid index prior to the episode of atrial fibrillation (AF) and post theepisode of atrial fibrillation (AF), and is configured to derive fromthis comparison a recovery indicator, or an indicator of an absence ofrecovery after atrial fibrillation (AF).
 15. A method for detectingatrial and ventricular events comprising: receiving an endocardialsignal using an acceleration sensor; gathering an endocardialacceleration signal received during ventricular pacing with a pluralityof atrioventricular delays with differing AVD values; deriving from thegathered endocardial signal a value, corresponding to each AVD value ofsaid plurality of atrioventricular delays, of a parameter representativeof a component of the endocardial acceleration signal; evaluating adegree of variation in said parameter values corresponding to saidplurality of atrioventricular delays; and discriminating between normalatrial mechanical activity and absent or deficient atrial mechanicalactivity.
 16. The method of claim 15, wherein evaluating a degree ofvariation in said parameter values corresponding to said plurality ofatrioventricular delays comprises: calculating a difference between thevalues of said parameter collected for a first range of AVD values andvalues of said parameter collected for a second range of AVD values,wherein said first range of AVD values includes a plurality of short AVDvalues, and wherein said second range of AVD values, distinct from saidfirst range of AVD values, includes a plurality of long AVD values. 17.The method of claim 15, wherein evaluating a degree of variation in saidparameter values corresponding to said plurality of atrioventriculardelays comprises: calculating a standard deviation of said parametervalues collected for said plurality of AVD values.
 18. The method ofclaim 15, wherein evaluating a degree of variation in said parametervalues corresponding to said plurality of atrioventricular delayscomprises: modeling a sigmoid characteristic (MS) of the parametervalues as a function of said plurality of AVD values, with two plateaus,one on each side of a central transition portion.
 19. The method ofclaim 15, further comprising comparing a degree of variation in saidparameter values to an index of values, measured over time, wherein saidindex of values contains values of the degree of variation of theparameter values.
 20. A method comprising: evaluating a degree ofvariation in a set of endocardial acceleration ventricular parametervalues corresponding to a plurality of atrioventricular delays; anddetermining if the degree of variation in a set of endocardialacceleration ventricular parameters is a significant variation, whereinthe endocardial acceleration ventricular parameter is representative ofa component of the endocardial acceleration signal, and wherein asignificant variation indicates normal atrial mechanical activity andthe absence of a significant variation indicates absent or deficientatrial mechanical activity.